The Pendulum Swings Between Individualism vs. Collectivism in US Healthcare. What Does the Next Decade Hold?

Communities don’t think, don’t believe, don’t want, don’t have needs, don’t have interests and don’t make decisions. Only individuals have minds that generate desires and needs – and only individuals can make choices and decisions. Harry Browne- Libertarian Candidate for American President, 1996 and 2000

When I visit my European in-laws, some who work in healthcare, I’ll often regale them with American Healthcare Horror Stories. They’ve heard the one about the $25 Aspirin and the $117,000 bill from the assistant surgeon in New York. They’ve also heard the $1.5M surgical robots now doing many surgeries about as well as they were done earlier, at far higher cost. (Blogger Paul Levy has stayed on top of this story). They laugh when I tell them about the $235 Million proton accelerators being put in around the country, despite the lack of great data to support their use in many cases.

Last time, over a round of drinks, my brother-in-law looked at me and asked “how do you allow your money to be spent like that?” The answer, I suggested, has a lot to do with how you define “you”. The struggle is all about the rights of the “me” and the interests of the “we”. Over the past few decades, we’ve been pretty good about allowing people to buy what they want, at any price, with a community pot of money.

It’s not a new story. Since its founding, the United States has been a collection of people torn between — on one hand defending the rights of an individual to do what he or she wants — and on the other meeting the needs of a community of people. Healthcare isn’t exempt from this basic tension.

Marketers and futurists Roy Williams and Michael Drew (drawing on the work of William Strauss and Neil Howe’s Generational Theory) make a strong argument that this me/we conflict has been a consideration for most American history. American culture, policies, values and sympathiescycle (like a pendulum) from collectivism to individualism. At each end of the arc these tendencies become unbalanced and excessive, before correcting.

According to Williams and Drew (these are their illustrations) the collectivist period lasts for twenty years (ten years toward an extreme version of collectivism and ten years normalizing back):

The individualistic period also lasts for twenty years (ten years rising toward an extreme individualism and ten year normalizing back):

Once you understand the 40-year cycle (and the authors make a compelling case for history repeating itself) you can predict what the future is going to look like in terms of cultural values. If you’re wondering, Drew and Williams argue that for the past few decades we’ve been steadily approaching a “we” Zenith that will occur in 2023. For the next ten years society will be be firmly “we” focussed.

What does this mean for healthcare?

I’ve been thinking a lot about the book and about Strauss and Howe’s work in defining the generations and their behaviors. Understanding the cultural zeitgeist is critical for anyone in healthcare trying to plan. (You don’t want to build a healthcare Kibbutz if we’re entering a period of mercurial individualism).

The passage of PPACA a few years ago was certainly significant. But, for many Americans, the idea that a stranger would meddle with your right to choose healthcare will remain an exposed nerve: in the 2009 presidential election, Sarah Palin famously played on the anxieties of many Americans by seeding the “death panels” brouhaha, an allegation called “lie of the year” by the Tampa Bay Times’s Politifact.

If Drew and Williams are right, we are headed into a decade of greater emphasis on community. But Palin didn’t get it right: rationing of important and valuable services isn’t and wasn’t on the table. There are more than enough healthcare resources to go around.

Instead, I’d argue that society is going to insist on greater oversight and transparency of the care that’s available for purchase. The future will be about controlling unreasonable variation, weeding out the bad medicine and putting a foot down when marginal utility meets eye-popping prices (e.g. proton therapy for tumors that do just as well with gamma radiation). Individuals can get the services they want– but only if they work and are fairly priced (so long as the rest of us are expected to pay). As I’ve written before, my sense is that patients are looking for carefully and well curated, fully transparent healthcare. They (we) will be willing to pay only for value.

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“Managing capitation can be deceiving. Like flying an airliner, the gauges, levers and controls can make it seem like high-stakes science. It is, partly. But as with all things healthcare this is ultimately about humans, their needs and their behaviors. You eventually learn that managing the payment model is as much an art as is the actual practice of medicine”.